County Pays Edgemoor Death Fine

Without admitting wrongdoing, San Diego County on Monday paid a $12,500 fine in connection with the death of a 93-year-old woman who was accidentally fed through her windpipe at the county’s Edgemoor Geriatric Hospital in Santee.

Lorna Doone Bone, who was terminally ill at the time of the accident, died at the hospital Jan. 9, several hours after the feeding tube was administered incorrectly.

An investigation by the state Department of Health Services and the county coroner determined that Bone’s death was an accident caused by county employees at Edgemoor.

As a result, the state on March 24 assessed the county $25,000, the stiffest possible fine.

But the county on Monday took advantage of regulations permitting an agency fined by the state to pay only half the penalty if the fine is paid within five days.

Deputy Chief Administrator Richard Jacobsen said the county paid the fine after determining that it could cost more to fight the penalty in court. He said county officials ‘remain bewildered” by the state’s finding that Bone’s death was preventable.

The state report said the Edgemoor nurse who made the mistake had not performed a nasal feeding in more than four years. The report said she was not familiar with the equipment used and took none of the proper precautions to ensure that the tube had been properly administered.

When Bone later started coughing and breathing heavily, neither the nurse nor two nurses’ assistants realized that she was distressed, the report said.

Edgemoor is a 323-bed hospital that takes elderly, handicapped and mentally ill patients who have nowhere else to turn.

After state and local investigations revealed poor patient care, management and maintenance at the hospital a year ago, Edgemoor’s administration was reorganized, minor repairs were made in its deteriorating buildings and plans were put in place for major structural changes at the one-time county poor farm.

Jacobsen said conditions at the hospital have improved in the last year. He said he is “confident the quality of care at Edgemoor is excellent.”